Occupational Medicine

S. Salehpour M.D.Occupational Medicine Specialist

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• About 45% of the world’s population and 58% of the population over 10 years of age belong to the global workforce.

• Importance:– Health– productivity– Socioeconomic issues– Sustainable development.

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• Only 5 10ـ % of workers in developing countries and 20 50 ـ % of workers in industrialized countries have access to occupational health services.

• approximately eight out of 10 of the worlds workers live in newly industrialized countries.

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Rapid change of the modern working life:

• Increasing demands of learning new skills

• Need to adapt to new types of work

• Pressure of higher productivity and quality of work

• Time pressure

• Growing psychological workload

• Stress

Scope of the Occupational Health and Safety Challenges

• Priority areas for research have changed over time as disease patterns have been altered by economics and change in work processes.

• Asbestos use has decreased in developed nations and asbestosis is far less common. Vinyl chloride-induced liver cancers and byssinosis have almost been eliminated.

• Since 1970, fatal injury rates in coal miners have been reduced by more than 75%, and the prevalence of coal workers' pneumoconiosis has had a general downward trend. However, silicosis persists, especially in foundries and mines, and lead poisoning continues to be reported.

• Occupational lung diseases persist. Nearly 30% of chronic obstructive pulmonary disease and adult asthma may be attributable to occupational exposure, and 9 million workers are occupationally exposed to known sensitizers and irritants associated with asthma.

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• Allergic and irritant dermatitis (contact dermatitis) are overwhelmingly the most important cause of occupational skin diseases, and they account for 15% to 20% of all reported occupational diseases.

• Latex in protective gloves causes contact dermatitis or urticaria in 10% of exposed health care workers. Prevention is critically important since 75% of patients with occupational contact dermatitis may develop chronic skin disease.

• Research on the effects of various chemicals on reproduction, including birth defects, stillbirths, low birth weight, developmental disorders, and impotence, remains meager.

• Noise is the most important occupational cause of hearing loss resulting from acute trauma or, more likely, chronic exposure to ototraumatic agents. Factors such as heat and chemicals may interact in causing hearing loss.

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The Role of Surveillance in Occupational Health

• Occupational health surveillance entails the systematic monitoring of health events and exposures in working populations in order to prevent and control occupational hazards and their associated diseases and injuries.

• Occupational health surveillance systems, has four essential components :

Gather information on cases of occupational diseases and injuries and on workplace exposures

Analyze the data Disseminate organized data to necessary parties,

including workers, unions, employers, governmental agencies, and the public

Intervene on the basis of data to alter the factors that produced these health events and hazards

• Surveillance in occupational health has been more concisely described as counting, evaluating, and acting.

• The word surveillance derives from the French word surveiller, watch over, which encompasses the twin notions of careful observation and timely intervention.

• It is important to emphasize that the enumeration and documentation of cases of occupational disease and injury is inseparable from the obligation to attempt to alter the conditions that led to the described occupational health morbidity and mortality.

• This obligation to take preventive action on the basis of surveillance data stems from a well-defined series of moral, ethical, and legal responsibilities of employers, governmental agencies, and unions.

• Medical surveillance refers to the ongoing application of medical tests and procedures to individual workers who may be at risk for occupational morbidity to determine whether an occupational disorder may be present.

• Medical surveillance is generally broad in scope and represents the first step in ascertaining the presence of awork-related problem.

• A medical surveillance program applies tests and procedures to a group of workers with common exposures for the purpose of identifying individuals who may have occupational illnesses and for the purpose of detecting patterns of illness among the program participants, which may be produced by occupational exposures.

• In occupational health, there are two kinds of surveillance activities: (a) public health and medical surveillance

(b) hazard surveillance

• Hazard surveillance is the monitoring of exposure to chemical agents, physical hazards, or radiation in the workplace. The two types of surveillance data complement each other.

• The main purpose of occupational health surveillance is to identify the incidence and prevalence of known occupational diseases and injuries.

• Gathering descriptive epidemiologic data on disease incidence and prevalence on an accurate and comprehensive basis is an essential prerequisite for establishing a rational approach to the control of occupational disease and injury.

• Collection of incidence and prevalence data permits an analysis of trends of occupational disease and injury among different groups, at different places, and during different time periods.

• Detecting such trends is useful for determining control and research priorities and strategies as well as for evaluating the effectiveness of any intervention undertaken

• Finally, occupational health surveillance is an important means of discovering new associations between occupational agents and accompanying diseases.

• The potential toxicity of approximately 80% of the chemicals used in the workplace has not been evaluated in humans.

Occupational Sentinel Health Events

• NIOSH defined the occupational sentinel health event as a disease, disability, or untimely death which is occupationally related and whose occurrence may:(a) provide the impetus for epidemiologic or industrial

hygiene studies;

(b) serve as a warning signal that materials substitution, engineering control, personal protection, or medical care may be required.

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• The goal of a multidisciplinary occupational health and safety team is to design, implement, and evaluate a comprehensive health and safety program that will maintain and enhance health, improve safety, and increase productivity.

• Such programs often provide similar results for the families of workers, with resultant financial and other benefits for the corporation.

• Occupational health and safety professionals include:– Occupational medicine physicians – Industrial hygienists – Safety professionals – Occupational and environmental health nurses – Occupational health psychologists – Other related members of the multidisciplinary

team:• Ergonomists • Toxicologists • Epidemiologists• Human resource specialists • Industrial/organizational psychologists

Safety and health statistics

• Indicators of safety and health at work:

– Indicators of outcome– Indicators of capacity and capability– Indicators of activities

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Work-related ill health and occupational disease (HSE)

• Over 12 000 deaths each year are estimated to have been caused by past exposure at work - primarily exposure to chemicals and dusts.

• An estimated 1.1 million people who worked in 2011/12 were suffering from a work-related illness, of which 452 000 were new cases which started in the year .

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• Around 80% of the new work-related conditions in 2011/12 were musculoskeletal disorders or stress, depression or anxiety.

• Other work-related illnesses include skin disease, respiratory disease, hearing loss and vibration-related disorders

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Global estimates of occupational burden of disease (WHO)

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• According to the estimates by the International Labour Organization (ILO) for accidents and diseases, there are globally about 2.2 million work-related deaths annually.

• Of this total, about 350,000 deaths are due to fatal occupational injuries

• The largest share of work related fatalities is made up by fatal diseases: 1.7 2 ـ million deaths annually.

• Almost half of these fatalities occur in Asian countries.

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• In a 2005 report, the ILO utilizes a variety of national reports to generate estimates, and states that the global workforce of 2.8 billion persons suffer some 270 million serious non-fatal injuries and 160 million work-related diseases.

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• Occupational risk factors such as the following, contribute markedly to global illness and injury:

37% of back pain 16% of hearing loss 13% of Chronic Obstructive Pulmonary Disease (COPD)

11% of asthma 9% of Trachea, bronchus lung cancer 8% of injuries 2% of leukemia

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History of Occupational

Diseases

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Silicosis- Ancient Disease of Miners

Detected among Mummies of workers in Egypt (1500 BC)

Described by Hyppocrites as disease of metal miners (400 BC)

In the 16th century Agricora wrote of mines in Carpathian Mountains in Europe:

“ women are found who have married seven husbands , all of whom

this terrible consumption has carried off to a premature death.”

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• Ancient Greeks were familiar with lung disease in quarry workers (Hippocrates) and the fact that respirators could prevent the disease (Pliny).

• Agricola (1566) described disease in stone cutters as later did Ramazini (1713).

• By 1917, the U.S. Public Health Service identified sand blasters and foundry workers to be at high risk of silicosis.

• The Gauley Bridge disaster with 475 deaths in 1931 focused public attention on silicosis in America. Lawsuits in the 1920s and 1930s resulted in workers' compensation coverage for occupational disease.

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The World-wide Problem

• There can be no question that the risks of injury and lung illness were realized to be a part of the miner’s life, even in 16th century.

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Ancient times

• Egypt, Greece and Rome– Mining one of the oldest industries– miners – slaves, criminals– work = punishment– miners used bags, sacks, animal bladders

as masks to decrease dust exposure

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Late 19th, early 20th century

• Development of government agencies and professional associations

• ILO– created 1919 – declared anthrax occupational disease– 1925 – 1st list of Occupational Diseases

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• According to the principles of the United Nations, WHO and ILO, every citizen of the world has a RIGHT to healthy and safe work and to a work environment that enables him or her to live a socially and economically productive life.

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Occupational Health

• The definition of occupational health has broadened considerably and there has been a transition from the strict concept of “prevention of occupational injuries and diseases” to “overall protection and promotion of workers’ general health”.

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بيماري هاي شغلي

بيماري هاي مرتبط با كار (سل در يك پرستار)•

بيماري هاي ناشي از كار (سيليكوزيس، •آزبستوزيس)

بيماري هاي مرتبط با كار

بيماري هاي ناشي از كار

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Occupational diseases

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قانون كار

براي صيانت نيروي انساني و منابع مادي كشور •رعايت دستورالعمل هايي كه از طريق شوراي

عالي حفاظت فني(جهت تامين حفاظت فني) و وزارت بهداشت، درمان و آموزش پزشكي (جهت

جلوگيري از بيماري هاي حرفه اي و تامين بهداشت كار و كارگر و محيط كار) تدوين مي شود، براي

كليه كارگاه ها ، كارفرمايان، كارگران و كارآموزان الزامي است.

ماده )85 )

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92ماده

اين قانون كه 85كليه واحدهاي موضوع ماده •شاغلين در آنها به اقتضاي نوع كار در معرض بروز بيماري هاي ناشي از كار قرار دارند بايد

براي همه افراد مذكور پرونده پزشكي تشكيل دهند و حداقل سالي يك بار توسط مراكز

بهداشتي، درماني از آنها معاينه و آزمايش هاي الزم را به عمل آورند و نتيجه را در پرونده

مربوطه ضبط نمايند.

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:92 ماده 1تبصره • چنانـچه ـبا تـشخيص ـشوراي پزـشكي نـظر داده ـشود ـكه ـفـرد ـمعايـنه ـشـده ـبه بـيـماريـ ناـشي اـز ـكار مبتال ـيا ـدر مـعرض ابـتال باـشـد، كارفرـما وـ مـسئولين ـمربوـطه مـكلفـند ـكار اـو را ـبرـ اـسـاس نظرـيه ـشـورايـ پزـشكي قسـمت درـ ، السـعيـ حـقـ اهـش ـك دون ـب مـذكـور

ـمناسبـ ديگري تعيـين نمايـند.

:92 ماده 2تبصره • در ـصورت مـشاهده ـچنين بيـماراني، وزارت ـكار و مجـدـد دـ تايـي و دـ بازدـي هـ ـب فـ مكـل اجتمـاـعي امـوـر ـشرائط ـفني و بهداـشت و ايـمني محـيط ـكار خواـهد

بود.

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175ماده

، 78متخلـفان ـهر ـيك از ـموارد ـمذكور در ـمواد •راي ـهر ـمورد تخـلف 92 و 82 ، 81 ، 80 ـب

ه تادـي ا ـي ف تخـل ع رـف ر ـب عالوه ورد ـم حـسب حـقوق ـكارگر ـيا ـهر دو، در مهـلتي ـكه دادـگاه ـبا امـور و كـار وزارت نماينـده نظـر كسـب ر ـه ازاي ه ـب رد، ـك د خواـه يين تـع اجتمـاعي

كارگر به ترتيب ذيل محكوم خواهند شد: برابر حداقل 100 تا 30 نفر ، 10) براي تا 1

مزد روزانه يك كارگر.

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(ادامه...)175ماده

10 نفر، 10 نفر نسبت به مازاد 100) براي تا 2 برابر حداقل مزد روزانه يك كارگر. 30تا

نفر، 100 نفر نسبت به مازاد 100) براي باالتر از 3 برابر حداقل مزد روزانه يك كارگر.10 تا 5

تا 1/1در صورت تكرار تخلف ، متخلفان مذكور به برابر حداكثر جرائم نقدي فوق و يا به حبس 5/1 روز محكوم خواهند شد.120 روز تا 91از

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Early detection of occupational diseases

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نظام مراقبت از بيماري هاSurveillance

راي ـب ا پوـي سيسـتمي آوري ع ، جـمل و تحلـي ا تفسـير ـب ط مرتـب اطالعـات

راي ـب ه ـك اـست زيـسالمتي رـي ه ، برناـم ـخدمات ـسالمت ـضروري ارزـيابي و اـجرا

ا اين اطالـعات توزـيع ـبه موـقعـبوده و ـب همراه است. افراد ذي نفعبه

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What is Occupational Surveillance?

• Systematic monitoring of:– Hazardous exposures– Adverse health events

FOR THE PURPOSE OF

• Prevention and control of:– Occupational hazards– Occupational diseases and injuries

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Types of Prevention

Primary- aimed at the individual who has potential for exposure; has not yet developed the disease. Goal is to change exposure conditionsSecondary- focus is the individual in whom the disease has started but the symptoms have not appeared. Goal is to reverse symptomsTertiary- aimed at individuals in whom the disease is symptomatic. Goal is cure or control of disease.

Types of Prevention

Primary – Target: those with potential for exposure; no disease yet. Goal: change exposure conditions

Secondary – Target: those with early stage of disease, no symptoms yetGoal: reverse disease, delay symptom onset

Tertiary – Target: those with clinical disease Goal: cure or control of disease.

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Healthy Asymptomatic Symptomatic

Worker Disease Disease

Primary Secondary Tertiary

Prevention Prevention Prevention

Opportunities for Prevention

time

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Why might you start an occupational surveillance

program?

• Identify a problem and estimate its magnitude• Identify groups at risk• Monitor illness/injury trends in time and geography• Identify cases, workplaces, and industries for

attention• Identify new illnesses• Identify new hazards

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How might you use a surveillance program?

• Prioritize health problems

• Determine whether you need an intervention program

• Evaluate progress, success, or failure of an intervention program

• Provide planning data for cost-effectiveness and benefit analysis

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How would you organize surveillance?

HAZARD BASED

• Characterize hazards– Observation/checklist

• Monitor environment• Test workers

HEALTH BASED• Acute or chronic

injuries/illnesses• List of insurance claims• Death certificates• Health questionnaire• Physical examination• Lab testing for disease

markers

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What are the components of a surveillance system?

• Gather information on exposure & disease

• Analyze data

• Disseminate data in an organized form

• Use data to target or evaluate an intervention

• On-going

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غربالگري شاغلين

ا ـي ه ه معايـن ام هرگوـن انـج الگري غرـباختالل ايي شناـس ور منـظ ه ـب ي آزمايـشاري، بيـم ا ـي دن ـب اي ارگانـه در رد عملـكبيمـاري و اختالل آن ظهـور از قبـل

پزشـكي اسـت ه مداخـل ه ـك اني زـم در ،موثر و مفيد واقع گردد.

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ـبدون غرـبالگري در واـقع بررـسي اـفراد •شناسـائي عالمت راي ـب ود وـج ال احتـم مورد نظر است.بيماري

اـفرادي ـكه در آنـها احتـمال بيـماري وـجود •بيشـتر بررسـي جهت ، باشـد داشـته مـعرفي ـشده و آزمايـشات تكميلي ـبراي

ايشان انجام مي گيرد.

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Designing & Implementing a screening program

1. Assessment of workplace hazards

2. Identification of target organ toxicities for each hazard

3. Selection of a test for each screenable health effect

4. Development of action criteria

5. Performance of testing

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Designing & Implementing a screening program

6. Interpretation of test results

7. Test confirmation

8. Determination of work status

9. Notification

10. Diagnostic evaluation

11. Evaluation and control of exposure

12. Record-keeping

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Following conditions should be considered before a screening test is adopted:

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Moreover…

Sensitivity

• Sensitivity : measures the proportion of actual positives which are correctly identified as such (e.g. the percentage of sick people who are correctly identified as having the condition).

• Sensitivity relates to the test's ability to identify positive results.

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Specificity

• Specificity measures the proportion of negatives which are correctly identified (e.g. the percentage of healthy people who are correctly identified as not having the condition).

• Specificity relates to the test's ability to identify negative results.

• A sign or symptom with very high specificity is often termed pathognomonic.Salehpour 71

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انواع معاينات شغلي

Preplacement ExaminationsPeriodic ExaminationsReturn to Work AssessmentsExit ExaminationsEvaluation for Specific Occupational

Exposures or Diseases• …

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پايش بيولوژيكBiologic Monitoring

اـندازه ـگيري و ارزـيابي عواـمل ـشيميايي محـيط •ـكاـر وـ مـتابولـيت ـهاي آـنـها درـ نموـنه ـهاي بيولوژـيك ـبدنـ )ـهـوای ـبازدمیـ،ـخوـن، ادـرار، ـمو( ـبه منـظور ـارزـيابيـ مواجـهه و ـجذـب ـموـاد ازـ راهـهاي مختـلف

.)اسـتنشاق، بلـع يا ـجذب ـپوستي(

ابي مواجـهه • ارت اـست از ارزـي پايش محيطي عـبموـجود در محـيط ـشيـمياييـ ـادهـ ـم ك ـي ـا ـب ارجـي ـخ

كار.

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• Environmental Monitoring TLV*• Biologic Monitoring BEI

•BEI یا شاخص بیولوژیک تماس، حدود مجاز مرجع برای پایش بیولوژیک هستند.

� مقادیری • شاخص های بیولوژیکی تماس معموالهستند که در نمونه های بیولوژیک کارگر سالم با

یافت می شوند. TLVتماس شغلی در حد مگر...

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کاربرد پایش بیولوژیک

مستدل نمودن پایش هوا•ارزیابی اثربخشی وسایل حفاظت فردی•تعیین قابلیت نفوذ مواد از راه پوستی و •

گوارشیتعیین تماس های غیر شغلی•

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آيا پايش بيولوژيك و پايش محيطي الزاماz يك نتيجه را

نشان مي دهند؟، به دالئل زير:خير•روش هاي انجام كار در كارگران مختلف، متفاوت است.•راهها و سرعت جذب و متابوليسم مواد در افراد مختلف •

ممكن است متفاوت باشد.استفاده از وسائل حفاظت فردي، جذب مواد را تحت •

تأثير قرار مي دهد.ميزان جذب استنشاقي با تفاوت در ميزان تهويه، متغير •

خواهد بود.افراد با بافت چربي بيشتر، به ميزان بيشتري مواد •

محلول در چربي را در بدن تجمع مي دهند.

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منابع اصلی تناقض بین پایش بیولوژیک و پایش محیطی

وضعیت فیزیولوژیک و بهداشتی فرد•شرایط تماس شغلی•منابع تماس محیطی غیر شغلی• )Life style(شیوه زندگی فرد •روش کار نمونه برداری و تحلیل نتایج• زمان نمونه گیری•

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آيا براي تمام مواد شيميايي پايش بيولوژيك انجام پذير است؟

خير، بايد واجد خصوصيات زير باشند:•بيولوژيـك • محيطهـاي در نظـر مـورد ماده

ـوده و ـب يـري ـمناـسب ه ـگ رـاي ـنموـن ـب موـجود و وـرـد ـم جمـعيـت رـاـي ـب ـيـري ـگ هـ نمـوـن روـشـ يـزـ ـن

نظر قابل قبول باشد.ايج • نـت وده و داراي ـب اليز عملي آـن روش ـهاي

معتبر و قابل تكرار باشد.نتايج قابل تفسير باشند.•ل • قـب از ب مناـس ه مداخـل ايج، نـت ه ـب ه توـج با

تعريف شده باشد.

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